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Dr. David Derry Answers Reader Questions
Brought to you by Mary Shomon, Your Thyroid Guide
Index of Q&As with Dr. David Derry

Topic: Clinical Assessment of Thyroid Disease

A Reader Writes:

"I have Hashimoto's (diagnosed earlier this year, elevated antibodies present) but have intense vacillating periods/episodes of HYPER and hypothyroid related symptoms. Since my endo is completely baffled about this and is now "not convinced my symptoms are related to my thyroid..." (Consequently he's ordered a whole host of other tests to rule out other conditions), I'm trying to find more out more about Hashitoxicosis, as I think that's what is going on. And if I have it, how is it typically treated?"

David Derry Responds:

Dear Patient

If we ignore the lab tests and just look at the common clinical presenting symptoms of low and high thyroid or hypo and hyperthyroidism we can start to understand which is which. We will discuss adults here as the same problems may be different in children, teenagers and the elderly. Hypothyroidism diagnosed clinically far outweighs the number of cases of hyperthyroidism. Also the symptoms and signs of hyperthyroidism are not nearly as varied as seen when the patient is low thyroid.

Some of the symptoms in the textbook descriptions of thyroid problems are confusing but many are not. We will just trying to pin down which symptoms and signs help to tell you which you are.(1-7)

For example anxiety is common in both hypothyroidism and hyper so it is not a useful measure of your thyroid state. Panic disorder which is a more severe form of anxiety is almost always low thyroid.

Chronic fatigue is low thyroid.

Hyperthyroid patients especially the elderly sometimes have muscle weakness.

Muscle and joint aches and pains (fibromyalgia) is low thyroid

Lack of sweat is low thyroid

If you do sweat you could be either low or high thyroid.

If your temperature is low this is always low thyroid.

Normal temperature tells you nothing.

Constipation is low thyroid.

Intolerance to cold is low thyroid.

Dry skin low thyroid

Pulse rate is unreliable.

With a sustained high rate you would think hyperthyroidism. Pulse rates that are normal some time during the day means it is not hyperthyroidism. Hyperthyroidism keeps the pulse up and that is usually over 90 at rest. The confusing problem occurs when there is rise in pulse related to anxiety and panic reactions so common to hypothyroidism. Most often the rise in pulse is due to anxiety. If the pulse rate at some time during the day settles down to the normal range of 60-80 then the problem is likely low thyroid. In hyperthyroidism the pulse rate is maintained at a higher level all the time.

Some hypothyroid patients also have low pulse rates.

If the pulse goes up quickly from normal then it is likely anxiety and thus is low thyroid.

Not coping is low thyroid. One of the basic functions of thyroid is to maintain the ability to handle stress. Mainly psychological stress. For severe fear or terror of an overwhelming nature (like childhood abuse) will empty the thyroid rapidly to excrete thyroid hormones for the brain. Those people equipped with adequate thyroid function can cope with stress without thinking about it. That is the brain through the pituitary TSH quickly signals it needs more thyroid and the thyroid responds adequately.

Slow or muddled thinking (brain function)is low thyroid

If depression is part of your symptoms you are low thyroid

Memory problems are low thyroid. Memory problems are corrected in all age groups with thyroid hormone treatment. Reversing memory loss of too long a duration becomes progressively more difficult. If thyroid is given to adults soon after memory problems start then Alzheimer's and related dementias are avoided. In the textbooks on hypothyrodism it says "Dementia may occur and in the elderly patient and may be mistaken for senile dementia." (9)

Not able to multi-task is low thyroid.

Sleeping lots is low thyroid.

Weight changes are not reliable because most low thyroids gain weight but other low thyroids with high will-power can lose weight. Hyperthyroid usually lose weight.

So if you have a mixture of these, look for the ones that are strongly indicative of which place you are in overall. If your temperature is low then it is hard for you to be anything but low thyroid. So do not then interpret the pulse rise and anxiety that can happen in hypothyroidism as hyperthyroidism. It is rare for the symptoms to change back and forth. The change from high to low thyroid often takes months to occur.

It is also understood here that if you are on thyroid medication and these problems are still present then likely your dose is too low.

Often a good question to ask yourself is what is my biggest complaint? What bothers me the most? If it fatigue then you have a good idea you are likely low thyroid. If it is you are sleeping 17 hours a day, then again it is likely you are low thyroid. But the same goes for depression, memory loss and the others mentioned. So if you have a symptom that looks like it is supposed to be hyperthyroid when you know from your basic biggest complaint you are hypothyroid then the symptoms are really from being low thyroid.

There are many low thyroid symptoms that seem odd but are really indicative of hypothyroidism so I have just tried to simplify the concepts so that you can understand which you are. The same goes for lab tests. If your lab test suggests you are hyperthyroid and you have major low thyroid symptoms then you are not hyperthyroid the lab test is erroneous.

I hope this helps with some of the confusion you outlined in your question.


1. Larsen, R. Ingbar,S.H. Chapter 8 The thyroid gland. Williams textbook of endocrinology, Eds Wilson,J.D. Foster,D.W. Philadelphia:W.B. Saunders Co, 1992. page 357-487. Quote from page 447

2. Part four Thyroid diseases:thyrotoxicosis.,R.D. Intro Werner and Ingbar's The Thyroid, Philadelphia:Lippincott-Raven, 1996. pages 521-734.

3. Par five Thyroid diseases: Hypothyroidism. Werner and Ingbar's The Thyroid, Philadelphia:Lippincott-Raven, 1996. pages 735-887.

5. Crile,G. & Associates, Diagnosis and treatment of diseases of the thyroid gland. W.B. Saunders, Philadelphia, 1932.

6. Werner, A.A. Endocrinology, clinical application and treatment. Lea and Febiger, 1942.

7. Schon,M., Sutherland A.M., Rawson R.W.. Hormones and neuroses--The psychological effects of thyroid deficiency. In: Reiss M, editor. Psychoendocrinology. New York: Grune & Stration, 1958: 835-839.

About Dr. Derry:

Dr. Derry is no longer in practice.

These answers are personal opinions. Please discuss any ideas you get with your physician.

Born in 1937, I am at the cutting edge of the war baby boom. With one exception the baby boomers tend to do what I do in large numbers about ten years later. The exception was that after finishing my internship at the Toronto General Hospital in 1963, as I had planned, I started a PhD in biochemistry at the Montreal Neurological Institute at McGill University in Montreal. After completing my PhD, I was hired by the Department of Pharmacology at the University of Toronto to teach and do research. Within a short time I became a Medical Research Council Scholar, which meant the Medical Research Council of Canada paid my salary to do research. Domestic rearrangements suddenly placed five children between the ages of 5 and 9 under my care. I abandoned my research career and took all five children, a new wife and dog out west to Victoria British Columbia.

My aim in 30 years of General Practice (an honor and a privilege) was to learn carefully and persistently how to listen to the patient. This is the one area of medical research that has gone almost totally un-examined. Sir William Osler, who I feel was the greatest physician of all time, said: if you listen to the patient they will usually give you the diagnosis and if you listen even more carefully they will likely indicate the best treatment for them. Gradually with the help of multiple self-development courses over the years I learned to listen by just getting my ego out of the way. From my patients I learned everything. Because of the arrival of effective treatments with potential side-effects, in 1945 the out-dated Hippocratic oath of “do no harm” was replaced with a new principle of ethical patient care namely “Consider first the well-being of the patient.” Combining extensive medical-literature reading with what I learned daily from patients clarified which approaches and treatments assured the “well-being of the patient.”

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